Why is emergency contraception interesting to think with?

I promised that the next post would be about emergency contraception in Egypt, but I couldn’t resist first writing about EC more generally and describing debates about EC in the U.S.

From rape treatment to mainstream contraception

For more than four decades, medical researchers have known that there are methods you can use after sex to prevent – not terminate – pregnancy. Emergency contraception (EC) was first researched in the 1960s by physician-researchers trying to find a way to prevent pregnancies in survivors of sexual assault. They experimented in giving rape survivors high doses of regular oral contraceptive pills (OCPs). Later it was established that inserting a copper-bearing IUD after sex was even more effective at reducing pregnancy risk.

Remember that this was during the pre-Roe v. Wade era so there were political reasons for looking for a way of preventing pregnancy, rather than expecting to be able to resort to abortion, for women who got pregnant after sexual assault. But of course there are also enduring religious and public health reasons for wanting to find ways to prevent pregnancy, rather than end it with abortion.

Increasingly, knowledge about this contraceptive technique filtered out to a wider public and in the 1970s through the 1990s, there was an underground movement of women and doctors spreading the word about do-it-yourself emergency contraception. You just take several pills from a regular pack of birth control pills within 5 days after sex.

(There’s a website run by Princeton University’s Office of Population Research that tells you exactly how many pills to take depending on what brand of Pill you’ve got, and as far as I can tell, this website was actually the first health information website on the Internet.)

Even though this form of contraception has been known for decades, it’s only in the past ten years or so that emergency contraceptive pills (ECPs) have become more widely known and marketed as a contraceptive option for all women, not just rape survivors. There’s been a global movement to introduce “dedicated products” worldwide and to lobby for them to be made available without prescription. (A “dedicated product” is when emergency contraceptive pills are packaged and marketed specifically for that purpose. Activists have long argued that this is an important improvement on the DIY culture of cutting up packets of pills because it increases awareness of EC and lends the method popular legitimacy.)

EC is an intrinsically liminal technology

I spent 5 years or so following debates over EC in the U.S., before I decided to look at EC in Egypt. I think there are three curious properties of EC and EC users that make this a particularly interesting technology to study.

To paraphrase Victor Turner, EC is “betwixt and between.” Classified as a contraceptive, but used after sex, it is often confused with medication (aka medical) abortion. The hormonal version consists of higher doses of the same drugs used in regular daily oral contraceptive pills. Another version of EC that has been tested (but is little used outside of China) is mifepristone, the same drug that is used to induce early abortions (also known as RU486 or the “French abortion pill”), but at a much smaller dose than what is required to terminate a pregnancy.

These properties contribute to EC being imagined as simultaneously more than a contraceptive and less than an abortion. This makes EC particularly fertile ground for debate and contestation. During U.S. debates, there were a lot of attempts by opponents to classify the method as an abortifacient, not contraception, even though medical authorities define it as a contraceptive.

Another reason why this technology is ambiguous is because its mechanism of action – the way it works inside the body to prevent pregnancy – is hidden from view and essentially unknown. Scientists postulate that that EC may work through three mechanisms: inhibiting or delaying ovulation, preventing fertilization by altering the tubal transport of sperm or egg, or preventing the implantation of a fertilized egg in the uterus. It’s the last possible mechanism of action that is fiercely contested, because even though medical authorities define pregnancy as beginning with implantation, some religious interpretations define the beginning of life at fertilization.

But basically no one knows for sure. You can prove a post-fertilization effect of EC either way, because there is no clinical evidence in humans that can either prove or disprove whether EC actually might have a post-fertilization effect. Why? Basically because you can’t figure this out without cutting up women. There are studies in the monkey and the rat (that show no post-fertilization effect), but the extent to which these can be extrapolated from to describe what’s going on in human reproductive tracts is unknown. So the chance that EC has a post-fertilization effect can only be statistically modeled and indirectly inferred. It is this peculiar characteristic of EC that further lends itself to imagination about the inner workings of a woman’s reproductive tract when the medication is taken.

You can see this in the public hearing the FDA held when considering whether to make ECPs available over the counter or not. First, consider the testimony of Carole Ben Maimon, the CEO of Barr Pharmaceuticals:

“Plan B works like other progestin-only oral contraceptives and prevents ovulation. Plan B is an oral contraceptive, not an abortion pill. The direct evidence is highly in favor of the fact that the primary mechanism of action, if not the sole mechanism of action, is prevention of ovulation.”

She was clearly at pains to make the point. NOT AN ABORTIFACIENT. In contrast, here’s what Judie Brown, the president of American Life League, said in her testimony:

“Emergency contraception, first of all, is not contraception. So-called emergency contraception can by definition abort a child before that child implants. A human being beings at conception, not implantation. …If a human zygote cannot implant, he or she will die. This means that the pills act to prevent pregnancy by aborting a child…”

The third characteristic of this technology to consider here is that we don’t know much about EC users. There are structural reasons why there are very few qualitative, in-depth studies of the characteristics of users of EC. With many medical technologies, access to the technology is mediated through a specific point of entry into medical bureaucracies, and researchers can take advantage of this to study users of the technology. So if, say, you want to study people using in vitro fertilization (IVF), you stake out an IVF clinic and find a cooperative doctor that will let you talk to her/his patients. But with EC, there’s no one easily identified point of access. Some women go to their doctor to get it, but it’s not like there are doctors who specialize in EC like there are with IVF. You can get it from your family physician or from your gynaecologist. Some women get it straight from a pharmacist. Other women borrow a friend’s pack of pills and cut it up.

That’s part of the reason why it’s hard to find people who are using it. The other is that use is relatively rare. An individual woman’s need for EC is predicated on non-consensual sex or a contraceptive accident, so it’s unpredictable. Many women have never used EC. There have been a few large scale demographic studies of user populations, but very little qualitative description of the sexual and contraceptive experiences of individual users.

The result has been a great deal of speculation about the characteristics-and morals-of women who use (or need) EC and the men they had sex with. The debates about making EC available over-the-counter revolve around the imaginations of users: who is using it, who they’re having sex with, and why they need EC. Basically, in the FDA debates over EC, 2 poles of sexual behavior were theorized:

An exploitative male sexual predator, either a teen playboy who will use access to ECPs to convince women to engage in unprotected sex, or an adult sexual molester who will administer the pills to his victims to cover up his crimes. In this imagination of EC use, women are cast in the role of weak sexual gatekeeper whose ability to say no will fall apart in the face of new technologies.

Consider, for example, the testimony at the FDA hearings from Robert Marshall, a state legislator from Virginia. He said:

“One name that should be on this NDA [New Drug Application] is Hugh Hefner. Playboys, adolescent adult males are going to be the primary beneficiaries of this.”

Or Susan Crockett, a pro-life Bush-appointed representative on the FDA advisory board reviewing the EC application:

“Making ECs available would be a welcome tool for adult sexual predators who molest family members, children of friends or students. They could keep a stash in their bedroom drawer or their pocket to give their victims after committing each rape.”

The other archetype of EC user advanced at those FDA hearings was the image of a responsible, condom-using woman in a committed relationship with an equally responsible man. Eight members of the National Organization of Women (NOW) spoke at the FDA public hearing describing their own personal experiences using EC after consensual sex. In those accounts, 6 described a contraceptive failure, and 6 described the women being in a committed sexual relationship.

In considering the kinds of sexual encounters that are portrayed as typical in this debate, it’s also interesting to consider what portrayals of sex are absent. First, there’s no mention of non-heterosexual, non-penetrative sex, but we’ll bracket that off since this is a debate about contraception. Also absent is any depiction of:

● Consensual sex under the influence of alcohol, or
● getting “caught up in the heat of the moment” – i.e. no contraceptive used in the first place.

Much of the testimony from the NOW representatives described needing EC after a condom broke, but what about people who have sex without a condom in the first place? Don’t they have the same right to contraception as women who use condoms?

Incidentally, research strongly supports the idea that neither of the two poles of hypothetical sexuality portrayed in this debate are the face of “typical” American sexuality or, especially, of unintended pregnancy. A lot of people have consensual, unprotected sex, and these are the people who are overwhelmingly those who end up with unintended pregnancies.

But note that also absent in these two polar versions of the archetypical EC user is the possibility that women might be the exploiters, rather than men. The highly gendered portrayal of sexual encounters in the anti-EC position is revealed if we try a little thought exercise: can we imagine an alternative scenario in which the roles are switched? Imagine an older woman, figuratively hopping with STDs, who is trying to seduce a younger man into having sex without a barrier contraceptive by whispering into his ear, “Don’t worry, baby, you won’t be stuck paying child support payments for the next 20 years – I’ll take Plan B tomorrow morning.”

So that’s what EC debate has looked like in the US. What about elsewhere?
Debates over EC have taken strikingly different forms in the different countries in which it has been introduced, shaped by the social, cultural, religious, and political contexts. For example, in Latin America and Catholic-dominated countries, debate has often centred on EC’s mechanism of action and the moral status of a just-fertilized egg. In contrast, in most of the Muslim world, mechanism of action has not been a key issue, in part because of Islam’s very different religious interpretations of when life begins.

Now that I’ve set the stage by describing what EC is and why it’s such fertile ground (no pun intended) for societies to debate sexuality morality and when life begins, in the next posting I’ll talk about emergency contraception in the Arab world and in Egypt.

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In this post I’ve summarized work I’ve done with several colleagues: Angel Foster of Ibis Reproductive Health, who is both a medical anthropologist and a physician; James Trussell, the director of the Office of Population Research at Princeton University; and Joanna Erdman, a legal scholar who is the co-director of the International Reproductive and Sexual Health Law Programme in the Faculty of Law at the University of Toronto.